Chapter 6 Domestic resource mobilization and financing for ...
Domestic Financing for Health in Africa: The Road of Sustainability and Ownership
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Transcript of Domestic Financing for Health in Africa: The Road of Sustainability and Ownership
Domestic Financing for Health in Africa: The Road of Sustainability and
Ownership
Prof Alan Whiteside
The Global Fund Satellite Meeting
Cape Town
7 December 2013
Outline
1. Where we are: AIDS, TB and Malaria in epidemiological terms:
• Global burden of disease
• A Southern African example
• AIDS and malaria a major issue
2. What we need for 2014 – 2016
3. Two tipping points
• The economic transition theory
• The epidemiological and advocacy transition theory
• Real data
4. This meeting
Years of life lost (women) by cause: Global, 2010
Source: 2010 Global Burden of
Diseases Study
http://www.healthmetricsandevaluation.
org/
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
Years of life lost (women): Western Europe 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
Years of life lost (women): Western Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
Years of life lost (women): Central Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
Years of life lost (women): Eastern Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
Years of life lost (women): Southern Africa, 2010
Source: 2010 Global Burden of Diseases Study
http://www.healthmetricsandevaluation.org/
Maternal
Neonatal
HIV & TB
0-1 1-4 5-14 15-24 25-49 50 – 80 +
Age
Ante-natal prevalence South Africa
1990-2011
HIV Prevalence Among Pregnant Women: Botswana
37.4%
33.4% 32.4% 33.7%31.8%
30.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
2003 2005 2006 2007 2009 2011
What is needed for ATM 2014- 2016
• Estimated funding required $87 billion
• Available estimated funding $76 billion or 87%
– Domestic $23 billion certain
– Global Fund $12 billion: pledging 2- 4th December
– Domestic $14 billion potential
– International $10 billion very likely $24 billion hoped for
• Mind the gap: $13 to $39 billion
International Funding Uncertain
Global Priorities Changing: Post 2015 MDG
High Level Panel Report
How to sustain an HIV/AIDS Response?
1. Increase donor support: getting more from
existing donors or involving new donors
2. Increase government support
3. Decrease the cost of the current response by
improving efficiencies in existing programs
But prevent new infections!
Criteria for Investment in Health and ATM
• Level of national income, GDP or GNI. An approximation of
resources available within a country
• Degree to which the Government is able to raise revenue through
taxes, levies, domestic borrowing, or other means.
• Proportion of Government budget devoted to debt
• Pre-existing pattern of disbursement to different sectors. For health
if historical allocations have been low, infrastructure may be poor
reducing the short-run capacity to absorb rapid increases and convert to
service delivery.
Plan for Analysing “Fiscal Space”
• Macroeconomic analysis – Evaluating potential resource needs and resource
availability, identifying future resource gaps and potential ways of eliminating such financial gaps.
• Microeconomic analysis – Assessing potential opportunities to make the 3
largest interventions efficient:
• ART
• PMTCT
• OVC
Nu
mb
er
of
pe
op
le
Time
New Infections Deaths of HIV Positive People
Understanding Curves: New Infections and
Deaths
Nu
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of
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ple
Time
Treatment needed
People Requiring
Treatment
Treatment Requirements
Nu
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of
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Time
New Infections Deaths of HIV Positive People
Economic Transition
Credit Mead Over
Economic Transition
Data from South Africa
0
1000000
2000000
3000000
4000000
5000000
6000000
7000000
1985 1990 1995 2000 2005 2010 2015 2020 2025
HIVinfections
AIDS cases
AIDS deaths
Data from South Africa
0
100000
200000
300000
400000
500000
600000
700000
1985 1990 1995 2000 2005 2010 2015 2020 2025
New infections(Incidence)
AIDS deaths
No Economic Transition
on the horizon
Nu
mb
er
of
peo
ple
Time
New Infections Deaths of HIV Posive People
Treatment New people needing treatment
An Advocacy and
Epidemiological Transition
Epidemiologic Transition
Nu
mb
er
of
peo
ple
Time
New Infections Deaths of HIV Posive People
Treatment New people needing treatment
Epidemiologic Transition
Table 1: Domestic Investment 2011: % of total government expenditure
Rwanda 23.7%
Togo 15.4%
Botswana 8.7%
Malawi 18.5%
Zambia 16.0%
Nigeria 7.5%
Kenya 5.9%
Tanzania 11.1%
Source: UNAIDS, Oxford Policy Management and Authors own
calculations
Summary of three diseases
Source US $ billions
75% of an alcohol levy 3.9
Contributions from high-revenue enterprises 2.4
Airline levy by all African countries 1.7
2% of public sector budgets earmarked for AIDS 2.4
Mobile phone levy 2.0
1% income tax levy earmarked for AIDS 3.1
Recommendations 1
• Need for better data. We are not clear on who is spending what. This is true of
both domestic and international funding. Data needs to be improved and accessible.
• Political leadership is critical, and we need to develop advocacy messages to
ensure that health continues to be a priority.
• Revisit the economic arguments for health, including the macro-economic ones.
• Address rigid budgeting practices making it hard to reallocate revenues toward
health.
• Empowered Health officials to talk to finance and finance to understand health
• Address the perception that “donors will take care of the AIDS program”.
Recommendations 2
• Recognized and improved the role of civil society .
• The core question: it is possible to define the “right” mix of domestic and
international investment in any country. Initial thoughts this will vary country by country.
• We should establish on a country by country basis an acceptable “benchmark” for
countries to invest from their own resources.
• The Global Fund should work with other key donors as a „thought leader‟. In
particular it should look to providing data and information.
• This is a complex political question not just an economic one
Conclusions
1. Treatment is crucial
Medical
Moral
Ethical
Economic
2. Prevention is essential
We have to turn off the tap
This meeting is about
how do we find
innovative ways of
mobilising more
resources?
Thank You